Submission to the College of Physicians and Surgeons of Ontario
Re: Professional Obligations and Human Rights
Consultation on Physicians and the Human Rights Code
Ending 5 August, 2014
CI. Consultation process
CI.1 The College invited the public and the profession to provide feedback on
the policy by regular mail, email, and an on-line survey. In addition,
it provided an
On-line Poll and
Discussion Forum. The prompt for the On-line Poll, Discussion
and submissions was:
Do you think a physician should be allowed to refuse
to provide a patient with a treatment or procedure because it conflicts with
the physician’s religious or moral beliefs? (Yes) (No) (Don't Know)
CII.1.1 Respondents on the discussion page noted marked changes in voting
patterns suggestive of technological manipulation of the poll by both "yes"
and "no" respondents, and that some had difficulty registering their votes
(179, 183, 197). There seems to have been no geographical limitation on responses.
Thus, while the results seem to indicate overwhelming support for freedom of
conscience among physicians, the value of the poll is doubtful except as a
general indicator of interest in the subject and general trend among
CII.1.2 In fairness to the College, this kind of poll seems to be used on other
websites primarily to increase traffic and readership rather than as a
reliable source of data, and it probably did serve that purpose in the
CII.2 DISCUSSION FORUM (EMAIL, REGULAR MAIL, FORUM PARTICIPANTS)
CII.2.1 The Discussion
Forum included numbered entries by forum participants directed to the
College concerning the policy, as well as numbered entries with submissions
received by the College through email and regular mail. In addition,
forum participants posted replies and exchanged views in discussions under
individual numbered responses. Entries in these exchanges were not
CII.2.2 The College states that it received 1,797 responses, but there are only
1,270 numbered entries on the discussion page. The difference (+527)
is accounted for by the replies and exchanges under the numbered entries.2
CII.2.3 The present analysis concerns only the 1,270 numbered entries directed to
the College concerning the policy, which include 1,719 responses.3
DISCUSSION FORUM RESPONDENTS
Health Care Practitioners:4
Public & Anonymous:
DISCUSSION FORUM RESPONSES(Global)
Explicit statement to the effect that the existing policy is
satisfactory, without significant additional comments supportive of
freedom of conscience. (eg., 1159)
For freedom of conscience:
Supports physicians who refuse to provide services for reasons of
conscience. Frequently qualified by the rider that support is
limited to "non-emergency" situations or circumstances in which the
patient's life is not in danger. May include support for
status quo. (eg., 181)
Against freedom of conscience:
Opposes refusal to provide service based on conscientious
convictions or religious belief. Strength of opposition
varies. (eg., 1180)
Statements are not responsive to the issue (For example:
criticism of consultation, criticism of abortion, or no position
identifiable. (eg., 977)
Response in the form, "if will not provide, must refer." (eg.,
Makes suggestions attempting to balance what is thought to be the
physician/patient interest. (eg., 984)
DISCUSSION FORUM RESPONSES (Selected)
||Health Care Practitioners4
CII.3 ON-LINE SURVEY
CII.3.1 The following information is taken from a
Report provided by the College analyzing the results of the On-line
CII.3.2 Of the 6,400 surveys started, 3,103 were completed and 1,311 completed at
least one substantive question. The report concerns these 4,414
completed or partially completed surveys, 26 of which came from
organizations. Note that at least some of those who completed or
partially completed a survey also responded through the discussion page
above, but these respondents have not been identified by the College.
ON-LINE SURVEY RESPONDENTS
(policy staff, registrar, senior
Member of the Public:
Other Health Care Professional:
|Other professionals or concerned citizens
Report, Table 2 & Note 5
Clarity and Comprehensiveness
Report states that 54% of the respondents stated that Physicians
and the Human Rights Code clearly articulated a physician's
professional obligations, 55% thought it easy to understand, 57% thought it
well written, and most (58%) considered it well organized.
CII.3.4 However, it also notes that almost 27% had not read the policy, while the percentages above refer to the total number of responses,
not to the 73% who had actually read it.
CII.3.5 More confusing, the
Report indicates that its analysis of comments
on the comprehensiveness of the policy is based on 3,300 responses, again,
without reference to whether or not the respondents had actually read the
CII.3.6 It may be possible for the College to review the survey returns and limit
the analysis of clarity and comprehensiveness of the policy to the
respondents who actually read it. Unless that is done, its
analysis under this head will remain unsatisfactory.
CII.3.7 The following charts are derived from Figure 3 of the
percentages refer to a total of 3,117 responses. The charts are
arranged in diminishing order of agreement (i.e., either strongly or somewhat
agree), agreement indicated by dark blue shading. Bear in mind that most of the responses are from the general
public, so the charts do not represent the opinions of physicians.
CII.3.8 The subject of referral was handled differently. Respondents were
asked the following question:
When physicians refuse to provide
treatments or procedures on the basis of moral or religious belief, do you
think those physicians must be required, in all instances, to refer patients
to another physician or health care provider who will provide the treatment
(Yes) (No) (Don't know)
CII.3.9 The following chart is derived from Figure 4 in the
Report, which is based on 3,104 responses to this question.
CII.3.10 1,762 respondents provided further feedback on this question.
Presumably, the five examples of the feedback provided in the
Report are representative of all of the feedback.
- It seems criminal that a physician should be allowed to bill
the health care system for a visit from an existing or potential patient
and not at least provide them with a referral elsewhere;
- Referring a patient to another doctor is in some way collaborating
with or enabling a procedure the physician may consider immoral, and is
in some circumstances equivalent to murder;
- The physician can direct the patient to a directory of physicians to
find a new doctor. The physician who is morally/religiously conflicted
does not have to make a direct referral (doctor to doctor);
- They have no right to deny treatment. If they feel strongly about
their religious rights they need to find a different profession that
would make them more comfortable.; and
- If it is not an emergency situation, a physician should not be
required to provide information on where to obtain a procedure they are
morally opposed to. Patients are able to find that information
themselves if they so desire.
CIV.1 General Remarks
CIV.1.1 An unknown number of respondents contributed through more than one of the
consultation feedback portals (On-line Poll, On-line Survey, Discussion
Forum, email, regular mail) and the College has not (and perhaps cannot)
identify them. For this reason, it is not possible to derive from the
totality of consultation feedback a single, accurate global number of
responses in any of the six categories used in this analysis.
CIV.1.2 For present purposes, the On-line Poll is discounted because it is of
doubtful value (see above). Further, the
Report's analysis of the clarity and comprehensiveness of the existing
policy is also discounted because it is unsatisfactory (see
above). Hence, this discussion is limited to
the 1,719 responses/submissions in the discussion forum and to the
Report's analysis of between 1,762 and 3,117 On-line Survey responses
about policy issues.
CIV.1.3 A further point to note is that the College stated that the volume of
responses was unprecedented - more than 6,700.9
According to the briefing note for College Council, there were 6,710
responses, including "2296 comments posted to the online discussion page and
4414 completed online surveys."10
CIV.1.4 In fact, there were 3,103 complete and 1,311 partially completed surveys,
not 4,414 completed surveys.11 Moreover,
since an unknown number of respondents contributed both to the On-line Survey and Discussion
Forum, the number of unduplicated consultation responses actually
available for analysis may have been far less than 6,700. On the extremely contentious
issue of referral, for example, the College's analysis relies on less
than half that number (Figure 13).
CIV.2 Discussion Forum Responses (Email, regular mail, forum participants)
CIV.2.1 The comments posted in the Discussion Forum were unstructured responses to
Do you think a physician should be allowed to
refuse to provide a patient with a treatment or procedure because it
conflicts with the physician’s religious or moral beliefs?
CIV.2.2 Almost 80% of respondents in the Discussion Forum (including 68% of health
care practitioners, half of the medical organizations and 77% of other
organiztions) indicated their support for physician freedom of conscience by
affirming that they should be able to decline to provide services for
reasons of conscience or religion (Table C,
Figure 1). However, in many cases, this was
explicitly qualified by statements to the effect that this referred to
non-emergency situations, sometimes more specifically identified as
situations in which failing to provide the service would not endanger the
life of the patient.
CIV.2.3 About 11% of respondents indicated that they were against physician
freedom of conscience by affirming that they should not be able to
refuse services for reasons of conscience or religion (Table
C, Figure 1). This included 14% of health
care practitioners and 13% of other organizations (Table D,
Figure 2, Figure 4).
CIV.2.4 Only about 2% of respondents volunteered that objecting physicians should
be required to refer a patient to a colleague who would provide the service
(Table C, Figure 1).
In a number of cases it appears that the respondents did not appreciate that
referral involved a moral or ethical issue, and might not have made the
recommendation if they had. In others, it appears that the respondents
would not have altered their view even if they understood that a moral or
ethical issue was involved. Only 4% of responding health care
practitioners insisted upon referral (Table D,
CIV.2.5 Summary: The overwhelming majority of respondents who made
submissions through email or regular mail or as discussion forum
participants support freedom of conscience for physicians with respect to
refusing to provide non-emergency services. In contrast, they offer
virtually no support for a policy of mandatory
referral by objecting physicians.
CIV.3 On-line Survey: Policy Issues (re: policy statements)
CIV.3.1 It is instructive to arrange the policy statements in the On-line Survey
in order of the level of overall agreement expressed with each (Figures
5 to 10).
CIV.3.2 With two exceptions, the reduction in the level of overall agreement corresponds to
reduction in the number of those who "strongly agree," but there is no
corresponding increase in the overall level of disagreement. Instead, the
overall level of agreement falls because more respondents seem to be in doubt about
how to interpret or apply the statements, reporting that they "neither agree
nor disagree" rather than that they "disagree" or "don't know." (Figure
11, Figure 12)
CIV.3.3 Two explanations can account for disagreement or doubt. First: the policy
statement may be perceived as excessively rigid, insufficiently attuned to
the realities of practice. Second: complying with a statement may be
perceived to involve complicity in a morally contested procedure.
CIV.3.4 These explanations are likely to be overlooked or dismissed as irrelevant by those bent on enforcing physician compliance with establishment expectations, but it is appropriate to consider them from the perspective of protecting the legitimate exercise of freedom of conscience. Explanations follow the references to the policy statements below.
Communicate clearly and promptly: The physician must communicate clearly and promptly to their patient about any treatments or procedures they choose not to provide because of the physician’s moral or religious beliefs.
CIV.3.5 It is common ground that conflicts should be avoided - especially in
circumstances of elevated tension - and that they often can be avoided by
timely notification of patients, erring on the side of sooner rather than
later. Thus, the high level of support for this statement (Figure
5) is not surprising. Nonetheless, some doubt or disagreement
about it might be attributed to concern about excessive rigidity.
Respondents who did not express support for this statement could have had
two scenarios in mind.
CIV.3.6 First: it is unreasonable to expect physicians to anticipate, in advance,
every conceivable request that might be made by patients. For example:
it would probably be unnecessary for a physician who accepts a 55 year old
single woman as a patient to begin their professional relationship by
disclosing objections to abortion, and it could well be unsettling for the
patient if her medical history includes abortion. And, while it is possible
that the woman might, six months after being accepted as a patient, ask for
an embryo transplant, it does not follow that the mere possibility of such a
request imposes a duty on the physician to disclose moral objections to
artificial reproduction at their first consultation.
CIV.3.7 Second: a physician may decline to provide a procedure for medical
reasons that are acceptable to his colleagues, but may also have religious
or moral reasons for refusal. In such situations, the physician might
believe that it is sufficient to advise the patient only of his medical
reasons because his decision does not not engage his moral or religious
Tell patients they can see another doctor:The physician must advise patients, or individuals who wish to become patients, that they can see another physician with whom they can discuss their situation if the treatment conflicts with the physician’s moral or religious beliefs
CIV.3.8 76% of survey respondents agreed with this statement, while disagreement
and doubt ("neither agree nor disagree") were almost equal: 11% and 12%
respectively (Figure 6).
CIV.3.9 The somewhat lower level of support for this statement might be
attributed to belief by some respondents that one becomes complicit in a
morally contested procedure merely advising a patient of his right to see
another physician. Members of the general public comprised almost 75% of the
survey participants (Table E), so disagreement or
doubt may reflect popular rather than professional views. In fact, the
Project has not encountered an objecting physician who would refuse to
advise patients that they can see a colleague.
Not express personal judgements:Physicians should not express personal judgments about the beliefs, lifestyle, identity or characteristics of a patient or an individual who wishes to become a patient.
CIV.3.10 A clear majority of respondents support the idea that physicians must not
"express personal judgments" about the beliefs, lifestyle identity or
personal characteristics of patients. The level of agreement drops to
71%, and the level of doubt is about the same, but here we encounter the
first exception to the general trend. In this case, the level of
disagreement rises from 11% to 17% (Figure 7).
Disagreement and doubt on this point are probably attributable to concern
about excessive rigidity, for two reasons.
CIV.3.11 First: many conditions treated by physicians are the result of patient
choices about diet and exercise, the use of alcohol, tobacco and illicit
drugs and other risk-taking behaviours: sometimes, even, of criminal
misconduct. Most people would agree that physicians are entitled to
express judgements about patient choices that are relevant to health.
However, such judgements involve a degree of subjective evaluation, and
patients may not appreciate the distinction between a "personal" and a
"professional" judgement. This is further complicated for physicians
whose religious beliefs conflict with patient choices, as when a religion
proscribes the use of alcohol and/or tobacco. Will they be accused of
violating this guideline, even if their advice is based on the same
reasoning and couched in the same terms as that of a colleague who does not
share their beliefs?
CIV.3.12 Second: there may be concern that ideologues will treat bona fide
compliance with the first policy statement (communicate clearly and
promptly) as a violation of this guideline. After all, a
physician cannot express a conscientious objection without first forming the
judgement that the treatment is immoral. It is reasonable to believe that
the communication of the objection, which the College requires, will cause
patients to infer (correctly) the beliefs of the physician concerning the
treatment. Patients may thus "feel judged" by the physician, even if the
physician's judgement pertains to the morality of the procedure rather than
the personal culpability of the patient. It would be unjust to require
physicians to disclose conscientious objections to patients and then
discipline them because a patient resents their beliefs, but this possiblity
might well explain why more respondents disagreed with this policy
Not promote own beliefs: Physicians must not promote their own moral or religious beliefs when interacting with patients.
CIV.3.13 We encounter the second exception to the general trend in the case of the
policy against promoting one's own beliefs. The level of agreement
drops to 61%, the level of disagreement rises to 23% and doubt increases to
15% (Figure 8). Once more, the most likely
explanation for this is that the policy is perceived to be excessively rigid
and fails to take into account the realities of practice.
CIV.3.14 That reality includes the fact that, if a physician communicates an
objection to a procedure or service (as required by the first guideline), a
patient may well challenge his objection. A physician may, quite
reasonably, provide further explanation or justification in subsequent
conversation - and later get a letter from the College advising him that the
patient has complained that he was "promoting his own beliefs." On the other
hand, if he fails to respond to the patient's challenge, the patient may
concude that he is acting arbitrarily, has something to hide, or is unable
to defend his position.
CIV.3.15 It is not surpising to find less support for a policy that may be
perceived to contribute to this kind of no-win scenario.
Provide information on all clinical options:The physician must provide information about all clinical options that may be available or appropriate based on the patient’s medical needs or concerns, even if the treatment options conflict with the physician’s moral or religious beliefs.
CIV.3.16 The requirement that physicians provide information about all clinical
options enjoys the same level of overall agreement as the preceding
statement (61%), but the level of disagreement falls to 9% and number of
responses indicative of doubt increases to 23% (Figure
CIV.3.17 Here, the lower level of overall support and much higher level of doubt
are most likely explained by concern about complicity.
CIV.3.18 Those who object to X for reasons of conscience may hold that "merely"
providing information is not necessarily a morally or ethically neutral act:
that providing information can make one complicit in morally contested
procedures. This position is neither unique nor unreasonable. In
fact, it is held by the General Medical Council of the United Kingdom,12
the American Medical Association.13
It was formerly the position of the College
of Physicians and Surgeons of BC.14 (See
also the comment of the Catholic Archbishop of Toronto, below.)
CIV.3.19 The possiblity that euthanasia and assisted suicide may be legalized by
the Supreme Court may also have influenced responses. Physicians who
believe that physicians should never be involved in killing patients because
patients are especially vulnerable to abuse may also believe that, in the
absence of a patient request, even advising patients of the option of
assisted suicide or euthanasia is an intrinsically abusive act.
Sometimes help to find another doctor:In some circumstances, the physician must help the patient or individual make arrangements to see another physician with who they can discuss their situation if the treatment conflicts with the physician’s moral or religious beliefs.
CIV.3.20 As noted above, the possibility of the legalization of assisted suicide
and euthanasia may also have influenced responses under this head. An
expectation that an objecting physician must sometimes help a patient find a
colleague "with whom they can discuss their situation" does not necessarily
amount to a requirement to help the patient obtain a morally contested
service, which many objecting physicians would find unacceptable because
they believe it would make them complicit in the act. However, it is
uncomfortably close to that. The Catholic Archbishop of Toronto made
this point in his submission:
The second expectation "Provide information about all
clinical options . . . " and the fourth "Advise patients or individuals . ..
" could have the potential for an infringement upon the rights of conscience
of a physician, depending on the extent to which he or she is required to
become actively involved in facilitating actions which go against his or her
conscience. A lot depends on what is involved in "help the patient or
individual make arrangements to do so."15
CIV.3.21 Hence, it is not surprising that the level of agreement in this case
drops to 55%, the level of "strong agreement" drops dramatically to 39%, the
level of disagreement is double that of the preceding guideline, and the
level of doubt rises to 26% (Figure 10).
CIV.3.22 Summary: Levels of support for policy statements
related to freedom of conscience for physicians decrease when they are
perceived as excessively rigid or insufficiently attuned to the realities of
practice. Levels of support fall and disagreement and doubt increase when
they are perceived to require complicity in morally contested procedures.
On-line Survey responses under this head do not support a policy of
mandatory referral, suggesting, instead, that such a policy is
CIV.4 On-line Survey: Policy Issues (re: mandatory referral)
CIV.4.1 With respect to a policy of mandatory referral, the change from requests
for levels of agreement with a policy statement to a "Yes-No-Don't Know"
response prevents comparison with responses to the preceding policy
statements. However, the concern here more clearly being the
perennially contentious issue of coerced complicity in morally contested
procedures, it is not surprising to find that the level of agreement drops
further to 50% and disagreement rises dramatically to 43% (Figure
CIV.4.2 Moreover, the sample of comments provided in the
Report indicate that the expressed levels of agreement and disagreement are
somewhat unstable, depending on factors or nuances not captured by the
1. It seems criminal that a physician should be allowed to bill the health care system for a visit from an existing or potential patient and not at least provide them with a referral elsewhere
2. Referring a patient to another doctor is in some way collaborating with or enabling a procedure the physician may consider immoral, and is in some circumstances equivalent to murder.
3. The physician can direct the patient to a directory of physicians to find a new doctor. The physician who is morally/religiously conflicted does not have to make a direct referral (doctor to doctor)
4. They have no right to deny treatment. If they feel strongly about their religious rights they need to find a different profession that would make them more comfortable.
5. If it is not an emergency situation, a physician should not be required to provide information on where to obtain a procedure they are morally opposed to. Patients are able to find that information themselves if they so desire.
CIV.4.3 Of the five comments, two (Comment 2 and Comment 5) appear to be taken from the
"disagree with mandatory referral" category, but Comment 5 disagrees only in non-emergency
CIV.4.4 Two seem to come from the "agree with mandatory referral" category, but only one (Comment 4) clearly favours coerced
participation. The respondent who offered Comment 1 seems unaware that
physicians who do not provide a service cannot bill for it, and that prudent
objecting physicians may not bill for a consultation that ends in refusal.
CIV.4.5 Comment 3 could have come from any of the three categories.
It reflects some of the ambiguity associated with the term "referral", and reflects
a solution that, in the Project's experience, most objecting physicians seem willing to accept.
CIV.4.6 Summary: On-line Survey responses do not support a
policy of mandatory referral. Rather, they indicate that mandatory
referral is a highly controversial subject.
This analysis uses spreadsheets in an Excel file, a copy of which is
2. Email from College of Physicians and Surgeons of
Ontario (firstname.lastname@example.org) to the Project Administrator, 9 February,
2015, 3:55 PM
3. Two of the numbered entries appear to be duplicates from the same
respondents (42-43, 70-71) and three are from the same organization
(1094,1263,1265). In this analysis, the duplicate and triplicate
entries are not counted. In some cases (eg., 526) the College noted
that it had received X number of identical responses, but posted only one to
represent the group. In this analysis, the actual number of responses
under a single entry is counted. In other cases, the single entry included either a joint
submission by more than one organization (1252) or represented the views of
more than one person (1035). In this analysis, the actual number of
persons/groups represented by an entry is counted, which is consistent with
the approach taken with respect to multiple identical submissions under a
4. Among health care workers, the College
identified only physicians (active and retired), categorizing nurses,
pharmacists, etc. as members of the public. In this analysis, all active
and retired physicians and medical students and health care workers are grouped as health
care practitioners, based on self-identification by the respondents in the
text of their submissions.
5. The College did not distinguish professional
medical organizations from other organizations. This analysis makes that
6. Categorizing responses may sometimes involve
subjective interpretation. In some cases, a different analyst might assign
a response to a different category. It is doubtful that this variation
would significantly change the numbers reported in each category.
7. Compulsory referral is considered by many objectors
to be a denial of freedom of conscience. Some respondents who expect
referral appear not to recognize that and consider their expectation to be
consistent with freedom of conscience. Others appear either to reject the idea
that any moral or ethical issue is involved in referral, or insist that the
physicians view must be suppressed in favour of the patient. Rather than
attempt a subjective evaluation to distinguish these views as either for or
against freedom of conscience, all responses in the form, "if will not
provide, must refer" are grouped together.
8. Figure 4 reported "Don't know" as 8%, which
would add up to 101%. It is reduced to 7% here to facilitate charting.
Physicians and the Ontario Human Rights Code Consultation, Online
Survey Report and Analysis.
"Balancing MD and patient rights: Human rights draft policy open for
consultation." Dialogue, Vol. 10, Issue 4, 2014, p. 49.
10. College of Physicians and Surgeons of Ontario,
Council Briefing Note: Professional Obligations and Human Rights -
Draft for Consultation (For Decision) (December, 2014). In
Annual Meeting of Council, December 4-5, 2014, p. 328
Physicians and the Ontario Human Rights Code Consultation, Online
Survey Report and Analysis, Table 1.
The GMC acted on this principle when it disciplined a physician who provided
information about the sale of organs but did not actually engage in the
practice. The Council found that the doctor had not participated in the
organ trade, but that his conduct amounted to "encouragement of the trade in
human organs from live donors". BBC News,
"Organ trade GP
suspended." 15 October, 2002 (Accessed 2015-02-01)
It has also applied this principle in guidance on assisted suicide.
Among the kinds of conduct that may constitute illicit facilitation or
cooperation in assisted suicide, the GMC includes: "encouraging a person to
commit suicide, for example, by suggesting it (whether prompted or
unprompted) as a 'treatment' option . . .providing practical assistance, for
example, by helping a person who wishes to commit suicide to travel to the
place where they will be assisted to do so . . . writing reports, knowing or
having reason to suspect that the . . . reports would be used to enable the
person to obtain encouragement or assistance in committing suicide. .
. providing information or advice about other sources of information about
assisted suicide, and what each method involves from a medical perspective .
. ." General Medical Council,
Guidance for the Investigation Committee and case examiners when
considering allegations about a doctor's involvement in encouraging or
assisting suicide: a draft for consultation. (Accessed 2015-02-01)
13. The AMA prohibits physicians from rendering
technical advice or consulting with executioners or "providing . .
.knowledge to facilitate the practice of torture." American Medical
Association Policy E-2.06:
Capital Punishment (June, 1998) (Accessed 2015-02-01); American
Medical Association Policy E.2.067:
Torture. (Accessed 2015-02-01)
14. The Deputy Registrar of the College of Physicians
and Surgeons of British Columbia (CPSBC)was horrified in August, 2005, when
he learned that a pre-natal gender testing kit was being marketed on the
internet. He described gender selection as "immoral." He explained that
College policy was not to disclose the sex of a baby until after 24 weeks
gestation in order to reduce the risk of gender selection, and that
physicians violating the policy were liable to be disciplined by the
College. Clearly, in this case, "providing information" (about the sex of
the baby) was not considered an ethically or morally "neutral" act. Lee,
slams 'sex selection' blood test: Gender of fetus can be seen five weeks
into pregnancy." Vancouver Sun, 13 August, 2005. (Accessed
2005-10-10). See also College of Physicians and Surgeons of British
Columbia, Resource Manual,
Selection Solely for Gender Determination (May, 2010). The
CPSBC revised the policy in January, 2012, apparently because of a legal
requirement to disclose information to patients. (College of Physicians and
Surgeons of British Columbia, Professional Standards and Guidelines,
Disclosure of Fetal Sex. (January, 2012) Accessed 2015-02-02.
15. Collins, T.
Letter to the College of Physicians and Surgeons of Ontario, 5
August, 2014. Discussion Forum entry 1171 (Accessed 2015-01-23)